DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for  Gender Affirmation Surgery 

Definitions

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Gender Dysphoria in Adults and Adolescents is a disorder characterized by the following diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders, 5th edition [DSM-5]):

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of

at least 6 months’ duration, as manifested by at least two of the following:

1.     A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics [(or in young adolescents, the anticipated secondary sex characteristics)].

2.     A strong desire to be rid of one’s primary and/or secondary sex characteristics because of marked incongruence with one’s experienced/expressed gender [or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)].

3.     A strong desire for the primary and/or secondary sex characteristics of the other gender.

4.     A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

5.     A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

6.     A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

 

Gender Dysphoria in Children: A disorder characterized by the following diagnostic criteria (Diagnostic

and Statistical Manual of Mental Disorders, 5th edition [DSM-5]):

 

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of

at least 6 months’ duration, as manifested by at least six of the following (one of which must be

criterion A1):

1.     A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).

2.     In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.

3.     A strong preference for cross-gender roles in make-believe play or fantasy play.

4.     A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender.

5.     A strong preference for playmates of the other gender.

6.     In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities.

7.     A strong dislike of ones’ sexual anatomy.

8.     A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

 

B. The condition is associated with clinically significant distress or impairment in social, school or

other important areas of functioning.

 

Gender Nonconforming (GNC) – is an adjective used as an umbrella term to describe people whose gender expression or gender identity differs from gender norms associated with their assigned birth sex.

 

Gender Reassignment Surgery (GRS) (gender affirmation surgery or sex reassignment surgery) – is defined as surgery to change primary and/or secondary sex characteristics to better align a person’s physical appearance with their gender identity. Sex reassignment surgery can be an important part of medically necessary treatment to alleviate gender dysphoria and may include mastectomy, hysterectomy, metoidioplasty, phalloplasty, breast augmentation, penectomy, orchiectomy, vaginoplasty, facial feminization surgery, and/or other surgical procedures.

 

Hormone Therapy (gender affirming hormone therapy, hormone replacement therapy) is the use of hormones to masculinize or feminize a person’s body to better align that person’s physical characteristics with their gender identity. People wishing to feminize their body receive antiandrogens and/or estrogens; people wishing to masculinize their body receive testosterone. Hormone therapy may be an important part of medically necessary treatment to alleviate gender dysphoria.

 

Puberty Suppression (puberty blocking, puberty delaying therapy) is a treatment that can be used to

temporarily suppress the development of secondary sex characteristics that occur during puberty in youth, typically using gonadotropin-releasing hormone (GnRH) analogues. Puberty suppression may be an important part of medically necessary treatment to alleviate gender dysphoria. Puberty suppression can provide adolescents time to determine whether they desire further transitional interventions for gender dysphoria and can additionally serve a diagnostic role to help determine if further medical intervention is warranted.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Covered Gender Affirmation Surgery* include:

 

·       Psychotherapy for gender dysphoria and associated co-morbid psychiatric diagnoses. (Most commonly mood disorders, anxiety disorders, and developmental personality issues.) The benefits are the same as any other outpatient mental health service.

·       Continuous hormone therapy. The benefits are the same as any other eligible medication within the prescribed treatment period.

·       Laboratory testing to monitor continuous hormone therapy is the same as any other outpatient diagnostic service within the prescribed treatment protocol.

·       Gender Reassignment Surgery (GRS)

·       Puberty suppression (puberty blocking, puberty delaying therapy) when determined to be medically necessary for treatment of gender dysphoria in adolescents.**

 

*Note this medical policy does not apply to individuals with ambiguous genitalia or disorders of

sexual development.

 

** Currently WV law bans puberty suppression. But beginning January 2024, there's an exception geared toward youth for whom “treatment with pubertal modulating and hormonal therapy is medically necessary to treat the minor’s psychiatric symptoms and limit self-harm, or the possibility of self-harm.”

 

Medical Necessity Guidelines

 

The following medical necessity criteria must be met:

 

A. Hormone Replacement Eligibility Qualifications

The Covered Person must meet all of the following eligibility qualifications for hormone replacement:

 

1) The Covered Person must be diagnosed with gender dysphoria (see definition below); and

2) Initial hormone therapy must be preceded by:

 

a) A documented real-life experience (living as the other gender) of at least three months prior to the administration of hormones (This documented real-life experience may substitute for the minimum psychotherapy requirement only upon certification by a qualified mental health professional experienced in the treatment of gender dysphoric and transgendered individuals); and

 

b) A thorough evaluation by a qualified mental health professional followed by a period of psychotherapy of a duration specified by a qualified mental health professional (Minimum of three months, though longer periods may be recommended. Psychotherapy may run concurrently.)

c) Informed consent for medical, psychological, and socio-cultural factors.

 

B. The Covered Person must then meet all of the following eligibility qualifications for gender

affirmation surgery:

1) The surgery must be performed by a qualified professional provider at a facility with a history of treating individuals with gender identity disorder, following appropriate informed consent for medical, psychological, and socio-cultural factors related to the procedure:

2) The treatment plan must conform to the World Professional Association for Transgender Health (WPATH) standards (WPATH 7th edition);

3) The Covered Person must be age twenty-one (21) years or older for irreversible surgical interventions.

 

• Written clinical evaluation that may be in the form of a letter documenting eligibility and medical

necessity from two qualified mental health professionals demonstrating that the member:

o Has been separately assessed by two qualified, mental health professionals, as defined

in this policy each resulting in a diagnosis of Gender Dysphoria meeting DSM-V criteria, and

o The qualified mental health professionals are unaffiliated.

• A written clinical evaluation by a qualified mental health professional will include at a minimum:

o Diagnosis of persistent gender dysphoria, with demonstrated participation in a treatment

plan in consolidating gender identity

o Diagnosis and treatment of co-morbid conditions,

o Counseling of treatment options and implications

o Psychotherapy for a minimum of 8 visits in the 12 months preceding surgery

o Affirmation that the member has been assessed face-to-face, in person, by the qualified

mental health professional

o Formal recommendations of readiness for surgical treatment, documented in a letter that includes:

·       Documentation of all diagnoses

·       Duration of professional relationship and the type of therapy

·       Rationale for surgery

·       A written description of the mental health professional’s strategy and approach

for providing coordination of care before, during and after surgery. This should

include regular contact by phone and in-person visits and may include

technology-based approaches.

·       A letter from the treating surgeon stating that the member meets the criteria listed

in the policy and has personally communicated to the treating mental health

provider, physician, and the member the ramifications of the surgery including:

• The required length of the hospitalization

• Possible complications of surgery/surgeries

• The post-surgical rehabilitation requirement of the various surgical

approaches and the planned surgery

• Pain management

• Completion of at least 12 continuous months of living as transgender Male to Female (MTF) or

Female to Male (FTM) in all aspects of daily living as documented in medical/psychological

records.

 

• Documentation of 12 months continuous hormone therapy as appropriate to the member’s

gender goals, unless medically contraindicated whereas the provider must document why the

hormones are not clinically indicated.

• Documentation of follow up every three months during the first year of hormone therapy to

monitor hormone levels.

• Documentation the member has received counseling about the risks, benefits, and alternatives of hormone therapy and surgery.

 

C. Age-appropriate screening for breast and cervical cancer should be continued unless mastectomy or removal of the cervix has occurred.

 

D. Age-appropriate screening for breast cancer is appropriate for male-to-female transgender patients. In patients who have a neocervix created from the glans penis, routine cytologic examination of the neocervix is indicated.

 

Gender affirmation services that are covered:

 

Male-to-Female (MTF)

 

o Orchiectomy

o Penectomy

o Vaginoplasty

o Colovaginoplasty

o Clitoroplasty

o Labiaplasty

o Augmentation Mammoplasty

o Perineoplasty

 

Female-to Male (FTM)

 

o Breast reduction (e.g., mastectomy, reduction mammoplasty)

o Hysterectomy

o Salpingo-oophorectomy

o Colpectomy/Vaginectomy

o Trachelectomy (Cervicectomy)

 

Providers for Gender Affirmation Surgery: All treating, rendering, ordering, or referring providers

MUST be enrolled with West Virginia Medicaid prior to services being performed. See Chapter 300,

Provider Participation Requirements. All providers must follow Policy 519.16, Surgical Services in addition

to this policy.

 

Provider Documentation Criteria for Gender Affirmation Surgery: The treating clinicians must provide

the following documentation. The documentation must be provided in letters from the appropriate

clinicians and contain the information noted below:

 

The letters must attest to the psychological aspects of the candidate’s Gender Dysphoria as defined by

the DSM-V.

 

a. One of the letters must be from a licensed behavioral health professional with an appropriate degree:

• Doctor of Philosophy (Ph.D.);

• Doctor of Medicine (M.D.);

• Licensed Certified Social Worker (LCSW)

• Doctor of Education (Ed.D.);

• Doctor of Science (D.Sc.);

• Doctor of Social Work (DSW);

• Psychiatric physician assistant, Doctor of Psychology (Psy.D), or psychiatric nurse

practitioner under the supervision of a psychiatrist with established competence and

clinical expertise in the assessment and treatment of gender dysphoria, who is capable of

adequately evaluating if the candidate has any co-morbid psychiatric conditions.

 

When patients with gender dysphoria are also diagnosed with severe psychiatric disorders and impaired

reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline

personality disorder), an effort must be made to improve these conditions with psychotropic medications

and/or psychotherapy before surgery is contemplated. Reevaluation by a mental health professional

qualified to assess and manage psychotic conditions should be conducted prior to surgery, describing the

patient’s mental status and readiness for surgery. It is preferable that this mental health professional be

familiar with the patient. No surgery should be performed while a patient is actively psychotic.

 

b. One of the letters must be from the candidate’s established physician or behavioral health provider.

The letter or letters must document the following:

 

• Whether the author of the letter is part of a gender dysphoria treatment team and/or follows

current World Professional Association for Transgender Health (WPATH) Standards of Care; or

• Endocrine Society Guidelines for the Endocrine Treatment of Gender-Dysphoric/ GenderIncongruent Persons for evaluation and treatment of gender dysphoria; and

• The initial and evolving gender, sexual, and other psychiatric diagnoses (if applicable); and

• The duration of their professional relationship including the type of evaluation that the candidate

underwent; and

• The eligibility criteria that have been met by the candidate according to the above Standards of

Care; and

• The physician or mental health professional’s rationale for hormone therapy and/or surgery.

• The extent of participation in psychotherapy throughout the 12-month real-life trial; and

• 12-Month Hormone Therapy

• Demonstrable progress on the part of the candidate in consolidating the new gender identity,

including improvements in the ability to handle:

o Work, family, and interpersonal issues

o Behavioral health issues, should they exist.

If the letters specified in 1a and 1b above come from the same clinician, then a letter from a second

physician or behavioral health provider familiar with the candidate corroborating the information provided

by the first clinician is required.

 

For members requesting surgical treatment, a letter of documentation must be received from the treating

surgeon. If one of the previously described letters is from the treating surgeon, then it must contain the

documentation noted in the section below.

 

All letters from a treating surgeon must confirm that:

• The member meets the “candidate criteria” listed in this policy and

• The treating surgeon feels that the member is likely to benefit from surgery and

• The surgeon has personally communicated with the treating mental health provider or physician

treating the candidate, and

• The surgeon has personally communicated with the candidate and the candidate understands the

ramifications of surgery, including:

o The required length of hospitalizations,

o Possible complications of the surgery, and

o The post-surgical rehabilitation requirements of the various surgical approaches and the

planned surgery.

 

Contraindications to Surgery

Patient exclusion criteria in the reviewed studies included an accompanying psychiatric disorder, severe

environmental challenges, failure to remain in a cross-sex role during the trial period, illicit drug use, or a

lack of Gender Dysphoria diagnosis.

Note: Coverage is limited to one sex transformation reassignment per lifetime which may include several staged procedures.

 

West Virginia Medicaid does not cover reversal of the surgeries approved under rule WV Chapter 519.24.

• Cryopreservation, storage, or thawing of reproductive tissue is not covered. Surrogate parenting

will not be covered.

• Coverage is not available for surgeries or procedures that are cosmetic, such as services that

change a beneficiary’s appearance but not medically necessary to treat the patients underlying

gender dysphoria.

The following procedures are considered cosmetic and not medically necessary when performed as part of  the gender reassignment services

 

o Abdominoplasty

o Blepharoplasty

Body Contouring (eg, fat transfer)

Breast enlargement, including breast implants and augmentation mammoplasty

o Brow lift

o Calf implants

o Cheek/Malar implants

o Chemical peel

o Chin/nose implants or prosthesis

o Collagen injections

o Dermabrasion

Face/forehead lift

o Hair transplantation/augmentation/reconstruction/hairplasty

Injection of fillers of neurotoxins

o Lip reduction

o Liposuction

o Mastopexy

o Neck tightening

o Pectoral implants for chest masculinization

o Removal of redundant skin

Rhinoplasty

Skin resurfacing

o Voice modifications such as laryngoplasty, glottoplasty or shortening of the vocal cords

o Gluteal augmentation

 

Non covered services are not eligible for a West Virginia Department of Health and Human Resources (DHHR) Fair Hearing or a Desk/Document review.

 

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

Place of Service: Inpatient/Outpatient

REIMBURSEMENT

 

Participating facilities will be reimbursed per their Highmark Health Options contract.